Kennon Heard

Association of Unintentional Pediatric Exposures With Decriminalization of Marijuana in the United States

STUDY OBJECTIVEnWe compare state trends in unintentional pediatric marijuana exposures, as measured by call volume to US poison centers, by state marijuana legislation status.nnnMETHODSnA retrospective review of the American Association of Poison Control Centers National Poison Data System was performed from January 1, 2005, to December 31, 2011. States were classified as nonlegal if they have not passed legislation, transitional if they enacted legislation between 2005 and 2011, and decriminalized if laws passed before 2005. Our hypotheses were that decriminalized and transitional states would experience a significant increase in call volume, with more symptomatic exposures and more health care admissions than nonlegal states.nnnRESULTSnThere were 985 unintentional marijuana exposures reported from 2005 through 2011 in children aged 9 years and younger: 496 in nonlegal states, 93 in transitional states, and 396 in decriminalized states. There was a slight male predominance, and the median age ranged from 1.5 to 2.0 years. Clinical effects varied, with neurologic effects the most frequent. More exposures in decriminalized states required health care evaluation and had moderate to major clinical effects and critical care admissions compared with exposures from nonlegal states. The call rate in nonlegal states to poison centers did not change from 2005 to 2011. The call rate in decriminalized states increased by 30.3% calls per year, and transitional states had a trend toward an increase of 11.5% per year.nnnCONCLUSIONnAlthough the number of pediatric exposures to marijuana reported to the National Poison Data System was low, the rate of exposure increased from 2005 to 2011 in states that had passed marijuana legislation.

Antivenom Therapy in the Americas

Envenomations are an important cause of injury in the Americas. While supportive care alone may result in an acceptable outcome, antivenom offers a specific therapy that can significantly reduce the injury and symptoms of the envenomation. Antivenoms are hyperimmune sera collected from animals immunised with venom. The antibodies contained in the serum bind and inactivate venom components. This leads to cessation or reversal of the toxic effects of the venom. The serum is often processed to increase the level of antibodies directed against venom components and decrease the amount of inactive proteins that may cause allergic reactions. The processing may include precipitation of inactive proteins, Chromatographic methods and cleavage of the immunoglobulins to form antibody fragments known as Fab or F(ab)2.In the Americas, antivenoms are produced to treat crotalid and Micrurus snake envenomations, Latrodectus and Loxosceles spider envenomations and Centruroides and Tityus scorpion envenomations. The indications, method of administration and incidence of adverse reactions differ greatly for each antivenom. The adverse effects encountered when using antivenoms are primarily allergic in nature. Anaphylaxis, which may be life threatening, is a major concern. Preparations to treat anaphylaxis must be made before initiating antivenom therapy. Serum sickness is also common with many of the antivenom preparations.

Reliability of the Glasgow Coma Scale for the emergency department evaluation of poisoned patients

The Glasgow Coma Scale (GCS) was developed for monitoring the mental status of head-injured patients in the intensive care unit. The purpose of this study is to determine the inter-rater reliability of the GCS for poisoning patients in the emergency department. Methods: This was a prospective, observational study. Two observers used a standard assessment checklist to determine the GCS of suspected poisoning patients. Inter-rater reliability was assessed with a weighted Kappa score. Results: A total of 39 patients were enrolled. Weighted kappa for the total GCS demonstrated excellent agreement. Agreement was also good for each component of the score. Conclusion: The GCS is a reliable tool for the evaluation of mental status of poisoning patients in the emergency department.

A Preliminary Study of Tricyclic Antidepressant (TCA) Ovine FAB for TCA Toxicity

Background. Animal studies suggest that tricyclic antidepressant antibody fragments (TCA Fab) may be a useful therapy for tricyclic antidepressant poisoning. The objective of this study is to determine if TCA Fab increases total serum TCA levels without raising free serum TCA levels in human overdose patients, indicating that TCA Fab effectively binds TCA. Methods. This was a prospective, dose escalation study of patients with mild to moderate TCA poisoning. Patients were treated with an escalating intravenous infusion totaling 7 or 14 gm of TCA Fab. The outcomes of interest were serum TCA levels (total and free), worsening of TCA toxicity, and adverse effects. Results. Seven patients were treated with Fab. Infusion of TCA Fab was associated with a dramatic increase in total serum TCA levels, while free TCA levels fell in both dosing groups. There were no significant changes in QRS duration, heart rate or mean arterial pressure associated with the Fab Infusion. Worsening of TCA toxicity did not occur despite marked elevation of total serum TCA concentrations. The two patients with the greatest prolongation of QRS showed a prompt shortening in their QRS duration temporally associated with the Fab infusion. Mild wheezing was observed in one asthmatic patient. Conclusions. 1) TCA Fab raises total serum TCA levels while lowering free levels in TCA poisoned patients; 2) no toxic effects were associated with the increase in TCA levels and no severe adverse effects were observed during the hospital course following Fab infusion.

Treatment of amitriptyline poisoning with ovine antibody to tricyclic antidepressants

We report clinical improvement with the use of an ovine antibody (Fab fragment) to tricyclic antidepressants for the treatment of toxic effects of amitriptyline on the central nervous system and heart in a 48-year-old man.

The effect of amiodarone pretreatment on survival of mice with cocaine toxicity

IntroductionCocaine is a common drug of abuse and use has been associated with ventricular dysrhythmias. Published guidelines suggest that amiodarone is the first line antidysrhythmic for ventricular tachycardia and fibrillation. However, the effects amiodarone in the setting of cocaine toxicity are unknown and unstudied. The purpose of this study was to evaluate the safety and efficacy of amiodarone pretreatment in a murine model of acute cocaine toxicity.MethodsThis was a randomized, blinded, placebo controlled investigation using male CF-1 mice weighing 29–37 g. First, the safety of an intraperitoneal dose of amiodarone (40 mg/kg) was confirmed in 5 mice. Second, based on preliminary investigations, an approximate intraperitoneal LD50 dose of cocaine (110 mg/kg) was identified and used as the cocaine dose in this study. Animals were then randomized to 2 groups. The control group received 0.5 mL of intraperitoneal 0.9% saline 30 minutes before cocaine. The study group received 40 mg/kg of intraperitoneal amiodarone (40 mg/kg) 30 minutes before cocaine. A blinded observer monitored mice for 2 hours after cocaine administration.ResultsNo mice in the amiodarone-only group developed any signs of toxicity or died. In the saline + cocaine group 31/32 (96.9%; 95% CI 83.8 to 99.9) mice seized with a median time to seizure of 2.5 minutes, and 23/32 (71.9%; 95% CI 52.3 to 86.3) died with a median time to death of 5.5 minutes. In the amiodarone + cocaine group 31/33 (93.9%; 95% CI 79.0 to 99.3) mice seized with a median time to seizure of 2.0 minutes, and 24/33 (72.7%; 95% CI 54.5 to 86.7) died with a median time to death of 6.0 minutes. All animals that died did so within 9 minutes. The difference in the proportion of animals dying in the amiodarone + cocaine group compared to the saline + cocaine group was 0.008 (−21 to 22%).ConclusionsIn this study, pretreatment with amiodarone in cocaine poisoned mice resulted in no change in seizure incidence or mortality. However, definite conclusions about the reason for these findings cannot be drawn from this model.

Lack of Toxic Effects Following Acute Overdose of Cellcept (Mycophenolate Mofetil)

Mycophenolate mofetil is an immunosuppressive drug used for prevention of graft rejection following solid organ transplant and for treatment of autoimmune disorders. We report a case of a 24‐year‐old female with lupus nephritis that presented following ingestion of 10 grams of mycophenolate in a suicide gesture. Serum levels confirmed ingestion. The patient was treated with decontamination and supportive care and recovered with no adverse effect.

Medication organizers (pill minders) increase the risk for unintentional pediatric ingestions

Abstract Objective: Medication organizers may help improve medication compliance; however, they may increase the risk of having an unintentional pediatric exposure. The objective of this study was to measure the association between a pediatric emergency department (ED) visit for an unintentional pharmaceutical ingestion and the use of a medication organizer in the household. Methods: This was a cross-sectional case control study at a tertiary care children’s hospital ED. Cases included subjects <6 years of age who were evaluated in the ED for an unintentional pharmaceutical ingestion. The control group presented to the ED for a non-injury complaint and was matched using age and sex. Results: The unadjusted odds ratio (OR) of risk for unintentional pharmaceutical ingestion with use of a medication organizer was 2.0 (95% CI, 1.3, 2.9). After adjusting for the presence of prescription medications in the home, the OR of risk for ingestion remained statistically significant at 1.8 (95% CI, 1.1, 2.7). The child obtained the exposure medication from the medication organizer in 63% of cases where a medication organizer was present in the home. Cases were more likely to have knowledge of, and previous contact with poison control centers (PCC) than non-injury controls. Overall, a large number of caregivers (36%) did not have any knowledge of PCC. There were also differences in smoking and use of seat belts between cases and controls. Conclusions: The use of medication organizers may be a risk factor for unintentional pediatric pharmaceutical ingestions, even when controlling for the use of prescription medications in the home. Further research is needed to evaluate the specific role of medication organizers, and subsequently, improve prevention strategies.

In response to “Balancing the risks and benefits of medication organizers”

We recognize scenarios that involve pediatric unintentional exposures involve many factors, some difficult to measure. These include (but are not limited to) the caregivers and their medical and social history, storage practices, medication containers, and other environmental and behavioral factors. As we stated, the medication organizer may be representative (rather than a direct cause) of other factors, such as polypharmacy or having more dangerous medications in the home, which may be the actual factor in the unintentional exposure that led to the ER visit. As we have stated, we did not include patients with any cognitive/developmental delay and recognized recall bias as a potential limitation (although we would expect this to be relatively minor given that the pill-minder exposures are well-defined and within a short period of the outcome). We did not address the use of other medication packaging safety mechanisms, as the focus of the paper was medication organizers. However, we agree that it would be important to evaluate other packaging mechanisms to demonstrate best possible methods for poison prevention. We disagree with the author’s argument that 100% of the included ingestions should occur with pill organizers. Very few outcomes are absolutely associated with exposures. For example, in Doll and Hill’s landmark study demonstrating the association between smoking and lung cancer, 30% of female lung cancer patients were non-smokers [1]. Research has demonstrated medication organizers improve medication compliance, however, it does not mean they should be used without caution. We interpret our findings as indicating that they may be a risk factor of unintentional exposures, and patients should be counseled on their safe use and storage.

Accessing the Poison ControlCenter in the 21st Century. Howdo Patients Find and Contacttheir Poison Control Center

Methods of accessing public services have evolved. It is unclear how the public locates contact phone numbers and communicates with poison centers. Methods: Prospective, observational survey on human exposure calls to the Rocky Mountain Poison & Drug Center over a 5-day period. Respondents were asked how they obtained the phone number for the poison center and whether they were calling from a cell phone or a landline. Results: The largest percentage of respondents (43%) located the poison center phone number via the internet and the majority of respondents (74%) called on a cell phone. Conclusion: Most callers use internet sources to find poison center phone numbers and cell phones to access poison centers.